Harshith’s ELOG

Jan 15 2021

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:


 75 year old house wife  resident of kasthala ,came to casualty with complaints of pedal edema and shortness of breath since 10 days  

History of present illness: 

Patient was apparently asymptomatic 15 days back,then developed loss of appetite  and started taking less food,followed which she was taken to govt hospital (gave some medication) following which she ate well and developed pedal edema,which was gradual,progressive and shortness of breath (grade 4),then upon advice from RMP,patient was brought to KIMS for further evaluation . No H/O fever,vomitings,loose motions  No H/O chest pain,palpitations   Outside reports Cue shows RBC-8-9/HPF pus cells-plenty     Serum creatinine-2.9 Blood urea-48  

Past history-

No H/O hypertension,DM,TB,asthma,epilepsy,CAD,CVA   

General examination:  

Patient is conscious,coherent,cooperative oriented to time place and person 

Pallor is present, no icterus, cyanosis , kylonechia, lymphadenopathy , pedal edema 


Vitals-Temp:101F ,BP140/100 ,PR- 86bpm


INVESTIGATIONS-
























DIAGNOSIS-

-INTRINSIC RENAL AKI SECONDARY TO       UTI

-HYPERKALEMIA SECONDARY TO AKI

TREATMENT-

  1. Fluid restriction(1L/day)
  2. Inj. Lasix 40 mg IV BD(Only if bp>110mmhg)
  3. Inj. Ceftriaxone 1 gm IV BD
  4. Inj. Pan 40 mgIV OD
  5. 2 egg whites/day
  6. Protein powder 2 tsp in one glass of milk
  7. Strict I/O charting
  8. Tab shelcal ct po od
  9. Tab Nodosis 500 mg PO BD
  10. Tab Alpha d 3 PO OD
  11. Tab Orofer  XT PO OD


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